improving the health care of lesbian, gay, bisexual and transgender

IMPROVING THE HEALTH CARE OF LESBIAN, GAY, BISEXUAL AND TRANSGENDER PEOPLE: Understanding and Eliminating Health Disparities

IMPROVING THE HEALTH CARE OF LESBIAN, GAY, BISEXUAL AND TRANSGENDER (LGBT) PEOPLE: Understanding and Eliminating Health Disparities

Kevin L Ard MD, MPH1, and Harvey J Makadon2 MD

The National LGBT Health Education Center, The Fenway Institute1,2; Brigham and Women’s Hospital1; and Harvard Medical School1,2, Boston, MA.

INTRODUCTION

The LGBT community is diverse. While L, G, B, and T are usually tied together as an

acronym that suggests homogeneity, each letter represents a wide range of people

of different races, ethnicities, ages, socioeconomic status and identities. What binds

them together as social and gender minorities are common experiences of stigma and

discrimination, the struggle of living at the intersection of many cultural backgrounds

and trying to be a part of each, and, specifically with respect to health care, a long

history of discrimination and lack of awareness of health needs by health professionals.

As a result, LGBT people face a common set of challenges in accessing culturally-

competent health services and achieving the highest possible level of health. Here,

we review LGBT concepts, terminology, and demographics; discuss health disparities

affecting LGBT groups; and outline steps clinicians and health care organizations can

take to provide access to patient-centered care for their LGBT patients.

LGBT DEFINITIONS, CONCEPTS, AND TERMINOLOGY

Sexual orientation, to which the first three letters of the

LGBT acronym refer, can be thought of as consisting of

three components: behavior, identity, and desire. These

components are not necessarily congruent in any given

individual. For instance, some individuals engage in

same-sex sexual behavior but do not identify as lesbian,

gay, or bisexual; others experience same-sex attraction

but are not sexually active with members of the same

sex. In one recent study of men in New York City, 73%

of those who reported sexual activity with men identified

as heterosexual; these men were more likely than their

gay-identified counterparts to be foreign-born, married,

members of racial or ethnic minorities, and of lower

socioeconomic status (Pathela 2006). More than three-

quarters of self-identified lesbians also report prior sexual

experiences with men (Diamant 1999).

Given the incomplete overlap between behavior, identity,

and desire, the terms “men who have sex with men”

(MSM) and “women who have sex with women” (WSW)

are often used in research and public health initiatives

to collectively describe those who engage in same-sex

sexual behavior, regardless of their

identity. However, patients rarely use

the terms MSM or WSW to describe

themselves. Other than “lesbian,”

“gay,” or “bisexual,” some patients may

prefer terms such as “same-gender

loving” to describe a non-heterosexual

sexual orientation (Potter 2008).

The T in the LGBT acronym stands

for transgender, which has been

used as an umbrella term to describe

individuals who do not conform to the

traditional notion of gender in which

one’s gender expression or desired

expression is consistent with one’s

birth sex. Transgender individuals

may alter their physical appearance,

often though not always through

hormonal therapy and/or surgery,

in order to affirm their gender identity. In the medical

setting, the term “male to female” (MTF) transgender has

been used to describe a person born with male genitalia

but who identifies as a female; the

term “female to male” (FTM) has

been used for the reverse. Gender

nonconformity, however, may take

other forms. Some reject the binary

nature of gender as being either

male or female; these individuals

may see themselves as ref lecting

some of each or neither gender and

refer to themselves as genderqueer,

bi gender or androgynous. Some

people will occasionally adopt

the gender expression of another

gender and dress to reflect this.

These individuals are referred to

as “cross-dressers.” While a great

deal has been learned about gender

development and expression, there

is still much research to be done and

understanding to be gained if we are

to be able to provide knowledgeable care to individuals

with non-conforming gender identities.

LGBT DEMOGRAPHICS

It is difficult to define the size and distribution of the LGBT

population. This is due to several factors, including: the

heterogeneity of LGBT groups; the incomplete overlap

between identity, behavior, and desire; the lack of research

about LGBT people; and the reluctance of some individuals

to answer survey questions about stigmatized identities

and behaviors. However, combining results from multiple

population-based surveys, researchers have estimated that

approximately 3.5% of United States adults identify as lesbian,

gay, or bisexual and that 0.3% of adults are transgender.

This amounts to approximately 9 million individuals in

the United States today (Gates 2011). Greater numbers of

individuals report same-sex behavior and attraction; in one

national survey of 18 to 44-year-olds, 8.8% reported a history

of same-sex sexual behavior, and 11.0% reported same-sex

attraction (Chandra 2011). In addition, the 2010 United

States Census identified more than 600,000 households

throughout the country headed by same-sex couples

(Abigail 2011); there is at least one such household in 99% of

all United States counties (Gates 2004). It is thus likely that

most clinicians have encountered LGBT individuals in their

practices, whether they are aware of such patients’ sexual

orientation and gender identities or not.

THERE IS STILL MUCH

RESEARCH TO BE DONE AND

UNDERSTANDING TO BE GAINED

IF WE ARE TO BE ABLE TO

PROVIDE KNOWLEDGEABLE

CARE TO INDIVIDUALS WITH

NON-CONFORMING GENDER

IDENTITIES.

2 IMPROVING THE HEALTH CARE OF LGBT PEOPLE

WHY IS LGBT HEALTH IMPORTANT?

Clinicians must be informed about LGBT health for two

reasons. First, there is a long history of anti-LGBT bias

in healthcare which continues to shape health-seeking

behavior and access to care for LGBT individuals, despite

increasing social acceptance. Until 1973, homosexuality

was listed as a disorder in the Diagnostic and Statistical

Manual of Mental Disorders (DSM), and transgender

identity still is (Potter 2008). In keeping with a pathologic

understanding of homosexuality and transgender identity,

many LGBT individuals were subjected to treatments such

as electroshock therapy or castration in the past (Context

2011). Such treatments have now fallen from favor in

the medical community and been formally disavowed

by many medical and professional societies, but some

clinicians continue to harbor anti-LGBT attitudes. As

recently as the 1990s, nearly one-fifth of physicians in

a California survey endorsed homophobic viewpoints,

and 18% reported feeling uncomfortable treating gay or

lesbian patients (Smith 2007). Attitudes have improved,

but in a national survey in 2002, 6% of United States

physicians still reported discomfort caring for LGBT

patients (Kaiser 2002). Because of prior experiences

of bias or the expectation of poor treatment, many

LGBT patients report reluctance to reveal their sexual

orientation or gender identity to their providers, despite

the importance of such information for their health care

(Eliason 2001).

LGBT HEALTH DISPARITIES

Second, although there are no LGBT-specific diseases,

clinicians must also be informed about LGBT health because

of numerous health disparities which affect members of

this population. Both a recent Institute of Medicine Report

and the Department of Health and Human Services

Healthy People 2020 initiative have highlighted these

disparities and called for steps to address them (IOM 2011,

Lesbian 2012). These disparities stem from structural and

legal factors, social discrimination, and a lack of culturally-

competent health care.

Members of the LGBT community are more likely

than their heterosexual counterparts to experience

difficulty accessing health care. Individuals in same-sex

relationships are significantly less likely than others to

have health insurance, are more likely to report unmet

health needs, and, for women, are less likely to have had

a recent mammogram or Papanicolaou test (Buchmueller

2010). These differences result, at least in part, from

decreased access to employer-sponsored health

insurance benefits for same-sex partners and spouses

(Mayer 2008).

Sexually transmitted infections, including human

immunodeficiency virus (HIV), are major concerns in

some LGBT groups, particularly MSM and male-to-

female transgender persons. MSM account for nearly

half of all people living with HIV in the United States,

despite making up approximately 2% of the general

population (CDC 2010). In addition, they accounted

for almost two-thirds of new cases of HIV in 2009, the

last year for which such data are available. In urban

areas, the HIV prevalence among MSM exceeds the

general population prevalence in many sub-Saharan

African countries where HIV is widely perceived as a

public health emergency (WHO 2008). Young, black

MSM, in particular, represent the only demographic

UNDERSTANDING AND ELIMINATING HEALTH DISPARITIES 3

group in which the incidence of HIV

is increasing, with an increase of 50%

from 2006 to 2009 (Prejean 2011).

Overall, black and other non-white

MSM are more disproportionately

affected by HIV than white MSM;

among black, urban MSM, the HIV

prevalence is estimated at 28%,

versus 18% for Hispanic and 16% for

white MSM (CDC 2010). The racial

disparities in HIV do not appear to

be due to differences in unsafe sexual

behavior but rather other factors, such

as decreased access to antiretroviral

therapy in non-white communities

(Oster 2011). Data on HIV rates in

transgender persons are sparse, but

a recent systematic review estimated

an HIV prevalence of approximately

28% in male-to-female transgender

persons in the United States (Herbst

2008). Aside from HIV, MSM account

for 63% of reported syphilis infections

and more than one-third of gonorrhea infections (CDC 2007,

Mark 2004). Antibiotic-resistant gonorrhea is also more

prevalent in MSM than other groups (Bauer 2005). Finally,

rates of human papilloma virus-associated anal cancers

among MSM are seventeen times those of heterosexual

men, with even higher rates among individuals concurrently

infected with HIV (CDC 2012).

Several other diseases and conditions are differentially

distributed between LGBT and non-LGBT groups.

Compared to heterosexual women, lesbians are more likely

to be overweight or obese (Boehmer 2007). In addition,

eating disorders and body image disorders may be more

common among gay and bisexual than heterosexual men

(Ruble 2008), and high school students of both sexes

who have same-sex sexual partners more commonly

engage in unhealthy eating behaviors than those with

only opposite-sex sexual partners (Robin 2002). There

is little data on cancer rates among LGBT individuals,

but some evidence suggests higher

rates of breast and cervical cancer

among lesbian and bisexual versus

heterosexual women (Valanis 2000).

If true, whether such differences stem

from lower rates of screening, greater

nulliparity or other factors is unknown.

LGBT and non-LGBT groups also

differ with regard to the prevalence

of substance abuse and mental

disorders. Members of the LGBT

population are approximately twice

as likely to smoke as the general

population (Lee 2009); indeed, they

have some of the highest smoking

rates of any sub-population (Tobacco

2008). In addition to tobacco abuse,

alcohol and other drug abuse may

be more common among LGBT

than heterosexual men and women,

although studies on this subject have

been conflicting and some have been

prone to methodological problems (Song 2008). In some

LGBT sub-populations, such as gay men and male-to-

female transgender persons, drug use is associated with

unsafe sex and the transmission of infections, including

HIV (Mayer 2008). Several studies have also suggested

higher rates of depression, anxiety, and suicidal ideation

among gay, lesbian, and bisexual individuals (Ruble 2008).

Although attributed to the pathology of homosexuality

or non-standard gender identity in the past, the higher

rate of substance abuse and mental disorders in LGBT

patients is now theorized to result from “minority stress,”

in which real or expected prejudicial experiences result in

internalized homophobia, depression, and anxiety (Meyer

2003). For many LGBT individuals, the minority stress they

experience on the basis of sexual orientation and gender

identity intersects with inequalities associated with race,

ethnicity, and social class (IOM 2011).

LGBT INDIVIDUALS FACE UNIQUE

CHALLENGES AS THEY AGE. THE

CURRENT COHORT OF LGBT

SENIORS GREW UP IN PERIODS

OF LESS SOCIAL ACCEPTANCE

OF LGBT LIFESTYLES AND

THUS MAY HARBOR GREATER

FEARS OF STIGMA AND

DISCRIMINATION THAN THEIR

YOUNGER COUNTERPARTS.


Finally, recent, highly-publicized cases of suicide

among teenagers bullied for being gay, lesbian, bisexual

or transgender have shed light on the violence and

victimization experienced by LGBT groups. Indeed, gay,

lesbian, and bisexual high school students are more

likely than their heterosexual counterparts to be injured

in a fight, threatened or injured with a weapon while at

school, experience dating violence, be forced to have

sexual intercourse, and avoid school because of safety

concerns (Kann 2011). LGBT adults are also victims of

violence; after race and ethnicity, sexual orientation may

be one of the most common motivations for hate crimes

(Massachusetts 2009). Such events often produce an

environment of stress and intimidation even for those not

directly impacted. While rates of intimate partner violence

appear to be similar between same-sex and opposite-sex

couples, partner abuse in LGBT relationships has been

under-recognized and under-addressed by the medical

community (Ard 2011). Intimate partner violence likely

affects transgender individuals more commonly than

those who are heterosexual, gay, lesbian, or bisexual

(Massachusetts 2009).

MARRIAGE, REPRODUCTION, AGING

Aside from health disparities, several other legal, political,

and social issues impact the health and well-being of

LGBT individuals. Marriage is a priority for many members

of the LGBT community, but same-sex marriages are

licensed in only six states; another two states recognize

same-sex marriages performed in another jurisdiction,

and another twelve states provide at least some state-

level spousal benefits to same-sex couples. Thirty-nine

states have laws banning same-sex marriage (NCSL 2012).

Other than permitting same-sex couples to receive the

same material and legal benefits available to others, the

right to marry has also been associated with greater

feelings of social inclusion among LGBT individuals,

whether married or not (Badgett 2011).

In addition to marriage, many LGBT individuals raise

children or have a desire to do so. In the 2002 National

Survey of Family Growth, 52% of gay men and 41% of

lesbian women expressed a desire to have children (Gates

2007). Approximately 19% of gay and bisexual men and

49% of lesbian and bisexual women report having had

a child (Family 2011). The pathways to child-rearing for

lesbian and gay couples vary. In many cases, children

being raised by same-sex couples are the products

of previous, opposite-sex relationships (Family 2011).

Otherwise, adoption provides a pathway to child-rearing,

although a few states explicitly ban same-sex couples or

gay or lesbian single individuals from becoming adoptive

parents. Even in the absence of explicit laws or policies,

individual adoption agencies vary in their willingness to

place children in the homes of LGBT persons. International

adoption is rarely an option due to other countries’ bans

on LGBT adoption (Adoption 2012). Donor insemination

and surrogacy are other options for building families,

although these may be prohibitively expensive for many.

Beyond marriage and child-rearing, LGBT individuals

face unique challenges as they age. The current cohort of

LGBT seniors grew up in periods of less social acceptance

of LGBT lifestyles and thus may harbor greater fears of

stigma and discrimination than their younger counterparts.

Such fears may become particularly acute when LGBT

elders are no longer able to live independently and must

move into communal housing arrangements or avail


themselves of social services, prompting some to newly

conceal their sexual orientation after years of living openly

(Johnson 2005). Less likely to have children, LGBT elders

may have fewer options for family support in the face of

illness and disability. Older adulthood may also be more

economically precarious for LGBT individuals, as they do

not have access to spousal, survival, or death benefits

through Social Security and thus may be impoverished

by the death of a spouse or partner (Joint Commission

2011). These challenges notwithstanding, many LGBT

persons demonstrate resilience as they age. Indeed, a

majority of respondents in one recent survey of aging

LGBT individuals felt that their LGBT status had prepared

them for aging by fostering inner strength (MetLife 2010).

SELF REPORT OF INFORMATIONON SEXUAL ORIENTATION (SO)

AND GENDER IDENTITY (GI)

DATAINPUT AT

HOMEARRIVAL

SO

/GI D

ATA

NO

T R

EP

OR

TE

DS

O/G

I DA

TAR

EP

OR

TE

D

REGISTERONSITE

INFORMATIONENTERED INTO

EHR

INFORMATIONENTERED INTO

EHR

PROVIDER VISITINPUT FROM

HISTORY

YES

NO

Figure 1. Gathering LGBT Data

in Clinical Settings: LGBT data

can be gathered at patient contact

points during the process of care

and integrated into the EHR

(Makadon 2012)

Figure 2. Structured Data on Sexual Orientation as Included with the Demographic Information at Fenway Health, Boston.

1. Which of the categories best describes your current annual income? Please check the correct category:

<$10,000 $10,000–14,999 $15,000–19,999 $20,000–29,999 $30,000–49,999 $50,000–79,999 Over $80,000

2. Employment Status:

Employed full time Employed part time Student full time Student part time Retired Other

3. Racial Group(s):

African American/Black Asian Caucasian Multi racial Native American/Alaskan

Native/Inuit Pacific Islander Other

4. Ethnicity:

Hispanic/Latino/Latina Not Hispanic/Latino/Latina

5. Country of Birth:

USA Other

6. Language(s):

English Español Français Portugês Русский

7. Do you think of yourself as:

Lesbian, gay, or homosexual

Straight or heterosexual Bisexual Something Else Don’t know

8. Marital Status:

Married Partnered Single Divorced Other

8. Veteran Status:

Veteran Not a veteran

1. Referral Source:

Self Friend or Family Member Health Provider Emergency Room Ad/Internet/Media/

Outreach Worker/School Other


CREATING A WELCOMING ENVIRONMENT

How can clinicians begin to address the health needs

of their LGBT patients? The first step is to create an

environment inclusive of all LGBT people. LGBT patients

report that they often search for subtle cues in the

environment to determine acceptance (Eliason 2001).

Simple changes in forms, signage, and office practices

can go far in making LGBT individuals feel more welcome.

For instance, intake forms can be revised to be inclusive

of a range of sexual orientations and gender identities.

The Institute of Medicine recommends inclusion of

structured data fields to obtain information on sexual

orientation and gender identity as part of electronic

health records (EHRs). Figure 1 illustrates a flow diagram

of possible ways to obtain such information. Patients can

be invited to input such information electronically, prior

to their visit, or at the time of registration; patients may

feel safer discussing their health risks and behaviors once

such information has been disclosed in this way, and

it streamlines the process of entering the data into the

electronic medical record. Allowing patients to enter their

own information into a database also relieves providers

from having to collect all the information about both sexual

orientation and gender identity during a busy clinical

encounter. Whether obtained via face-to-face history-

taking, paper forms, or secure electronic mechanisms,

information on sexual orientation and gender identity

permits clinicians to identify, and thus better meet the

health needs of, their LGBT patients. Regardless of how it

is obtained, this information can be entered into an EHR,

recognizing that it is critical to assure appropriate use of

the information and confidentiality. Figure 2 illustrates

a registration form used at Fenway Health in Boston

indicating how information regarding sexual orientation

is included with other demographic data in the context

of registration material. Figure 3 shows how information

that is helpful in the care of transgender individuals can

be obtained in a structured format; these questions were

developed by the Center of Excellence for Transgender

Health at the University of California at San Francisco.

Health care settings can also develop and prominently

display non-discrimination policies that include sexual

orientation and gender identity. All staff, including

receptionists, medical assistants, nurses, and physicians,

can be trained to deal respectfully with LGBT patients,

including using patients’ preferred names and pronouns.

Educational brochures on LGBT health topics can be

made available where other patient information materials

are displayed. The Joint Commission has recommended

these and other approaches in a recently published field

guide; it can serve as a self-assessment tool for clinicians

or healthcare organizations seeking to become more

inclusive (Joint Commission 2011). In addition, since 2011,

all healthcare organizations participating in Medicare or

Medicaid are required to allow patients to decide themselves

who may visit them or make medical decisions on their

behalf, regardless of sexual orientation or gender identity.

Figure 3. Recommended Data To Be Obtained

Regarding Gender Identity: Adapted from: Primary

Care Protocol for Transgender Patient Care, April

2011. Center of Excellence for Transgender Health.

University of California, San Francisco, Department of

Family and Community Medicine

1. What is your current gender identity? (Check an/or circle ALL that apply)

Male Female Transgender Male/Trans Man/FTM Transgender Female/Trans Woman/MTF Genderqueer Additional category (please specify):

Decline to answer

2. What sex were you assigned at birth? (Check one)

Male Female Decline to answer

3. What pronouns do you prefer (e.g., he/him, she/her)?


Beyond environmental cues and LGBT-

inclusive policies, clinicians can also

make strides in improving the health

of their LGBT patients by fostering a

welcoming environment within the

examination room and by educating

themselves about LGBT health topics.

Taking an open, non-judgmental

sexual and social history is key to

building trust with LGBT patients.

Rather than making assumptions

about sexual orientation or gender

identity based on appearance or

sexual behavior, clinicians should ask

open-ended questions, mirroring the

terms and pronouns patients use to

describe themselves. For example

rather than asking a patient: “Are

you married?” or “Do you have a

boy/girlfriend?”, consider asking “Do

you have a partner?” or “Are you in a

relationship?”, and “What do you call your partner?” Such

questions allow clinicians to initiate a discussion about

relationships and sexual behavior without assuming

heterosexuality.

In the process of obtaining information on sexual

orientation and gender identity, it may become clear

that clinicians are some of the f irst individuals to

whom patients have disclosed non-

heterosexual identity, behavior, or

desire. Reassuring responses from

health care providers may thus be

important for patients in the nascent

stages of “coming out,” or adopting

a public identity as a lesbian, gay,

bisexual, or transgender individual.

However, coming out is an individual

process unique to each person’s

family and social circumstances,

and aside from providing support,

clinicians should be wary about

encouraging or discouraging the pace

or form of this process.

Not all clinicians can become experts

in LGBT health, but they should

learn to address some of the specific

health concerns of this population

(Makadon 2006). Training about

LGBT health is sparse in medical schools; a recent report

demonstrated that a median of only five hours during

all of clinical training was devoted to LGBT issues at

United States and Canadian medical schools (Obedin-

Maliver 2011). In the absence of formal instruction in this

area, clinicians can turn to multiple national guidelines

and recommendations. For instance, the Centers

for Disease Control and Prevention (CDC) provide

RATHER THAN ASKING A

PATIENT: “ARE YOU MARRIED?”

OR “DO YOU HAVE A BOY/

GIRLFRIEND?”, CONSIDER

ASKING “DO YOU HAVE A

PARTNER?” OR “ARE YOU IN A

RELATIONSHIP?”, AND “WHAT

DO YOU CALL YOUR PARTNER?”

Figure 4. Recommended Annual† Sexual Health Screening for MSM (CDC)

HIV serology

Syphilis serology

Urine NAAT* for N. gonorrhoeae and C. trachomatis for those who had insertive intercourse in the past year

Rectal NAAT for N. gonorrhoeae and C. trachomatis for those who had receptive anal intercourse in the past year

Pharyngeal NAAT for N. gonorrhoeae for those with a history of receptive oral intercourse in the past year**

* Nucleic acid amplification test

** Pharyngeal testing is not recommended for C. trachomatis.

† The screening interval is shortened to 3-6 months for those with multiple or anonymous sexual partners or those who

use drugs in association with sex.


recommendations on the screening for and prevention

of sexually-transmitted infections in MSM (Workowski

2010). These include yearly screening for HIV, syphilis,

gonorrhea, and Chlamydia; the recommended screening

interval is shortened to three to six months for those at

particularly high risk, such as individuals with multiple

or anonymous sexual partners or those who use illicit

drugs in conjunction with sex (Figure 4). Hepatitis A and

B vaccination is also recommended for all MSM. Given

the high rates of HPV-associated anal cancers in MSM,

some authorities recommend anal cytology screening

for such patients, followed by high-resolution anoscopy

when abnormalities are found; however, the utility of

screening has not yet been demonstrated, and no formal

guidelines recommend this approach. Most would screen

HIV-infected MSM as well as those with peri-anal HPV

lesions (Palefsky 2012). The CDC recommendations

differ from those of the United States Preventive Services

Task Force (USPSTF), which support HIV and syphilis

but not Chlamydia and gonorrhea screening for MSM.

The Affordable Care Act has adopted the USPSTF’s

recommendations as the basis for reimbursement;

it is unclear if this will jeopardize payment for CDC-

recommended services (Fessler 2012). Lesbians and

bisexual women should be screened with Papanicolaou

smears and mammography as indicated for all women.

There are otherwise no formal guidelines regarding

screening for sexually-transmitted infections in lesbians

or bisexual women. Providers should screen these

individuals based on their risk factors, as determined

through a careful sexual history.

Given the high incidence of HIV in some LGBT

populations, HIV prevention constitutes a critical aspect

of the care of many LGBT patients. In addition to safer

sex counseling and the identification and treatment of

sexually-transmitted infections, non-occupational post-

exposure prophylaxis (nPEP) is recommended by the CDC

for those with a high-risk HIV exposure. nPEP consists

of the administration of antiretrovirals following a sexual

exposure to HIV. Therapy must begin within 72 hours

of exposure and is typically continued for four weeks

(Smith 2005). Providers uncomfortable prescribing nPEP

themselves should identify a local resource to which

patients can be referred in a timely manner; emergency

departments are often able to provide this service. For

patients at particularly high risk of HIV acquisition, a

recent study supports the use of pre-exposure prophylaxis

(PrEP) for HIV, consisting of daily antiretrovirals taken

in advance of sexual exposure along with provision

of condoms and safer sex counseling (Grant 2010).

Providers can access preliminary guidelines on the use of

PrEP at www.cdc.gov/hiv/prep.

Resources are also available to assist providers in learning

about the care of transgender patients. Online primary

care protocols for transgender patients are available

from the Center of Excellence for Transgender Health at

http://transhealth.ucsf.edu. In addition, the Endocrine

Society has developed clinical practice guidelines on the

prescription and monitoring of hormonal therapy for

transgender individuals, available at www.endo-society.

org/guidelines. An area of particular confusion for many

primary care providers is cancer risk and prevention in


transgender patients. In general, transgender persons

who have not undergone gender-affirmative surgeries or

used hormonal therapy should be screened for prostate,

breast, or cervical cancer according to established

guidelines for their birth sex. However, for those patients

who have undergone surgery or hormonal treatments,

screening recommendations must be modif ied; for

instance, mammography is suggested for male-to-

female transgender persons over age 50 who have taken

feminizing hormones for more than five years, due

to a theoretically increased risk for breast cancer, and

Papanicolaou smears are not indicated in the assessment

of surgically-constructed neovaginas (UCSF 2012).

Female-to-male transgender individuals should still

have mammography even if they have had breast tissue

removed in light of the possibility of developing cancer in

residual tissue.

CONCLUSION

The success of health-care organizations of all

types—from academic medical centers, community

hospitals, and community health centers to the many

community-based services with which they work to

ensure continuity of care—depends on providing high-

value care to patients that optimizes quality and

clinical effectiveness while keeping costs in check.

Central to doing so will be the practice of population

health using the model of the patient-centered

medical home (PCMH). In the case of LGBT people,

successful PCMHs must end LGBT invisibility in

health care by identifying the sexual orientation and

gender identity of their patients and then use this

knowledge to address the issues of greatest complexity

for the care of LGBT patients in a manner that is cost-

effective and informed by the best evidence available.

These issues include, but are by no means limited to,

behavioral health, HIV prevention, and transgender

care. In many ways, however, providing culturally-

competent care to LGBT patients does not differ from

providing patient-centered care to any other group. As

with all patient populations, effectively serving LGBT

patients requires clinicians to understand the cultural

context of their patients’ lives, modify practice policies

and environments to be inclusive, take detailed and

non-judgmental histories, educate themselves about

the health issues of importance to their patients, and

ref lect upon personal attitudes that might prevent

them from providing the kind of affirmative care that

LGBT people need. By taking these steps, clinicians will

ensure that their LGBT patients, and indeed all their

patients, attain the highest possible level of health.


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